Provider Demographics
NPI:1194882969
Name:SOUTHEAST HOSPICE NETWORK, LLC
Entity type:Organization
Organization Name:SOUTHEAST HOSPICE NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:205-706-6809
Mailing Address - Street 1:1635 MCFARLAND BLVD N STE 503
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2204
Mailing Address - Country:US
Mailing Address - Phone:205-366-9920
Mailing Address - Fax:
Practice Address - Street 1:4330 HIGHWAY 78 E
Practice Address - Street 2:SUITE 120-121
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8905
Practice Address - Country:US
Practice Address - Phone:205-387-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST HOSPICE NETWORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1663EMedicaid
ALPIC1663EMedicaid